<!DOCTYPE HTML PUBLIC "-//W3C//DTD HTML 4.0 Transitional//EN">
<HTML>
<HEAD>
<TITLE>Employee Insurance Signup</TITLE>
</HEAD>
<BODY BGCOLOR="#FDF5E6">
	<CENTER>
		<H1>Employee Insurance Signup</H1>
		<FORM ACTION="/servlet/coreservlets.SubmitInsuranceInfo">
			Name: <INPUT TYPE="TEXT" NAME="name"><BR> Employee ID: <INPUT
				TYPE="TEXT" NAME="employeeID"><BR> Number of Children:
			<INPUT TYPE="TEXT" NAME="numChildren"><BR> <INPUT
				TYPE="CHECKBOX" NAME="married" VALUE="true">Married?<BR>
			<CENTER>
				<INPUT TYPE="SUBMIT">
			</CENTER>
		</FORM>
	</CENTER>
</BODY>
</HTML>